I saw this article last week and had mixed feelings about it. I know that we were all supposed to read it and be horrified that a doctor was reprimanded for giving patients nutrition advice. After all, shouldn’t doctors be doing more to help patients manage their health through lifestyle changes? But… there’s so much that this article doesn’t tell us.

Just to start by clearing the air, obviously you all know that I’m a dietitian. Of course I’m going to feel a little defensive of my profession. The orthopaedic surgeon in question was undermining recommendations given by dietitians at the hospital where he worked. All because he had studied some nutrition on his own. Can you even imagine the outrage that would occur if the tables were turned and a dietitian undermined advice given by a doctor?! I’m certain that the RD would lose her (or his) licence, not just be given a slap on the wrist and told to stop working outside the scope of their practice.

Everyone think that they’re experts in nutrition simply because they eat (yes that’s hyperbole, please don’t send me your #notalleaters comments). So many people believe that doctors are all knowing. Unfortunately, it would seem that some doctors fall prey to this mode of thought as well. Doctors specialize. A doctor who works in oncology is going to have an entirely different knowledge-base and skill set from a doctor who works in neurosurgery. Doctors should not be expected to know everything. Yes, family doctors should be better equipped to provide nutrition advice but an orthopaedic surgeon should defer to the dietitians on-staff. It takes an incredibly high level of self regard to believe that you are more of an expert in a field in which you did a little self-study than a regulated health professional who studied the subject for over four years, is immersed in it on the job, and who must complete on-going education to maintain their credentials.

There’s some amazing irony in the article as well. The author references a television episode with the doctor in question and celebrity chef Pete Evans. For those who are unaware, Evans is a notorious charlatan and has faced entirely warranted criticism for promoting unsafe infant diets amongst other questionable nutrition practices. A few paragraphs down, the author goes on to say:

In addition there are numerous unqualified “gurus” giving advice about what we should and should not be eating. Surely it is preferable to have a doctor giving nutrition advice rather than unqualified individuals, many of whom have a product or program to sell.

Um HELLO??? Pete Evans is the epitome of the unqualified guru with a product to sell. Just prior to this statement, the author even admitted that the majority of doctors receive very little formal nutrition education. So, no. It’s not preferable to have a wholly unqualified doctor providing nutrition advice to people. In a way, it’s worse than having a self-proclaimed “guru” providing nutrition advice because people trust their doctors.

If the doctors referred to in the article truly cared about the well-being of their patients they would refer to appropriate professionals when needed, including registered dietitians. They should also work together with those professionals to provide the best care possible for their patients. Rather than assuming that they have superior knowledge of a subject which they were not adequately trained in.

How about rather than complaining foul when someone is rightly called-out for practicing outside their scope of practice, we talk about the real problem here. That our healthcare system is designed to treat illness rather than prevent it from developing in the first place.

Based on observation trainers are making at least two major errors when it comes to Corrective Exercise.

1) The Trainers failure to understand their scope of practice.
2) The Trainers failure to understand what Corrective Exercise actually is,where it fits in a training continuum and what it is they’re looking at.

I have education in corrective exercise. In the interest of transparency I’ll say I failed forward into it after being wrongly billed as a “Corrective Exercise Specialist.” My manager at the time knew NASM’s Certified Personal Trainer course heavily covered anatomy and had roots in Physical Therapy based approaches.

I figured to make things right I needed to live up to my billing and educate myself on the topic. One thing that I am decently good at is learning ,and being able to practically apply new information rather quickly. This was a need and expectation while I served in the military and I have two decades worth of practice doing it.

Corrective Exercise wasn’t something I would have volunteered for. Due to the fact that I was certified by NASM (and depressingly one of the few certified trainers on staff) I became the “resident expert on all things corrective exercise” by default. Based purely on a comparative basis this may have been true, but in reality this was far from the case. There were both positive and negative consequences to holding that (at least partially) undeserved reputation.

Being blunt, my molehill of corrective exercise knowledge was a mountain compared to everyone else. Problem is people don’t trip over mountains.

In hindsight I’m glad I did it. It opened up an entirely new area which I previously held no interest and added tools to my training repertoire that could be broadly applied. I stand by my opinion that the NASM CES is acceptable for learning the concepts of elementary level rehab exercise and does a very good job of teaching practical anatomy. Like any area of study, the exam only indicates a minimum level of knowledge as defined by the organization. It is on the trainer to continue learning and improving their skills.

The key words are elementary level. The NASM CES, good course that it is,really only scratches the surface of things. If you only read one book you’re limited to that level of knowledge no matter how many times you read it.

I’ve gone on to learn more corrective exercise and screening strategies over the years and two constants has remained the same. My approach continues to simplify and I’m quicker to refer out. What I do now bears near zero resemblance to what I was initially taught, although some fine details and lines of thinking remain intact. I don’t even use the word “dysfunction”

I encountered a situation recently where a trainer stated he had an enlarged Sternocleidomastoid (SCM) muscle along the left side of his neck which has become uncomfortable and is accompanied by pain shooting down his left arm. He wanted to know what corrective exercises could be applied to remedy this situation.

The Sternocleidomastoid muscle (Left) and all the neat stuff surrounding it.

When I read things like this my first thoughts are “what’s the worst things this could be?” Once again the military mindset reveals itself. The person could be right and it could be a muscle imbalance of some sort, but then again he could be very wrong.

The presence of pain shooting down the left arm alonesuggests the person visits their primary care manager. Enlargement of the SCM,presupposing it is the SCM and not something else.at my level of understanding and sight unseen of the person could indicate a number of things that CES won’t help.

CES trainers need to refer out clients for medical evaluations and treatment plans when things exceed their depth.

NASM’s Corrective Exercise Specialist (Left) and the Functional Movement Systems (FMS) are two of the larger and more established screening and correctives approaches. NASM states that diagnosis does not fall under the CES scope of practice and does not require a college degree if the candidate already holds an accredited Certified Personal Trainer credential. The FMS states explicitly where the FMS trained practitioner must refer to the higher level SFMA practitioner (Selective Functional Movement Assessment). SFMA holders are medically credentialed professionals.

Unless the CES course has radically changed over the last few years, it focused only on biomechanical issues that might lead to pain or some type of “dysfunction” BioMechanical issues are only one possibility when it comes to these things. One glance at the SCM images above shows we are pretty complex creations. CES doesn’t cover the other things that could be a factor such as neurological,endocrinological, disease state,structural et al…. the very same things that are outside of a trainer’s scope of practice and that no amount of Corrective Exercise will “fix”

Truthfully several CES recommendations can make matters worse. The otherwise innocent looking and popular foam roller for example is contraindicated in multiple conditions and thats not taking the more hardcore approaches into account.

CES has a place for clients that have been cleared of the more serious possibilities and for whom biomechanics have been determined as the main cause. Someone with a Dr title makes that call,a person with a deeper toolbox,imaging resources, understanding of many common health issues and ihow to properly work with them.

Yesterday I had an opportunity to shadow Dr. Michael Smith, ND: The founder of Carolinas Natural Health Center in Charlotte, NC and past-president of the North Carolina Association of Naturopathic Physicians.

Along with my long list of questions that Dr. Smith was so willing to answer, I was deeply encouraged by the small sampling of the patients I saw Dr. Smith working with…including those overcoming diabetes, candida, attention deficit disorder, hormonal imbalance, and much much more!

At the end of the day, I found myself even more excited to start a practice of my own…I just have to conquer 3 more years of naturopathic medical school…

Thank you Dr. Smith for taking time out of your busy schedule to answer my endless list of questions and for offering me so much wisdom from your years of practice. I look forward to gleaning more wise advice from you in the future!

Image by mkhmarketing on flickr. Used under a Creative Commons Licence.

One of my biggest pet peeves as a dietitian is the fact that so many non-dietitians fancy themselves to be nutrition experts. It’s one thing when it’s a “holistic nutritionist” at least they have some degree of nutrition education. It’s another entirely when it’s another regulated healthcare professional who seemingly has no concept of scope of practice. For those, such as the pharmacist I came across on twitter who states in her twitter bio “Pharmacist who would rather dispense nutrition than Rx.”, who may not know what scope of practice is: scope of practice describes the procedures, actions, and processes that a healthcare practitioner is permitted to undertake in keeping with the terms of their professional license. For a pharmacist, that means providing evidence-based advice and guidance on medications. For a dietitians, that means providing evidence-based advice and guidance on nutrition.

The pharmacist in question decided not to become a dietitian because she didn’t want spend the money to study the “low-fat” guidelines that apparently comprise the entirety of a degree in dietetics. How easy it is to be critical of a program when you clearly have no idea what the area of study consists of.

You know, I’d really like to be a pharmacist but I don’t agree with the excessive prescription of antibiotics. I think that instead of going to uni and studying pharmacology I’ll just start telling people what medications they should take for their ailments based on my own research and dispensing them online. Oh but that would be dangerous and I’d probably lose my licence to practice dietetics and face prison time. Yet, somehow it’s totally okay for someone who’s never studied nutrition to use their credentials as a regulated health professional (in a completely different field) to advise and influence people through social media, a blog, and conventional media. Ironically, as a registered dietitian I can’t even provide specific nutrition advice through those channels because sensibly one knows that I don’t have enough knowledge about the recipient of that advice to provide appropriate information.

Why even go to university for years, complete internships, pay to write a national exam, pay the college of dietitians $600 a year, and continue to learn about nutrition when it’s so easy? I could be cherry picking sensational “science” and promoting a “sexy” diet without having taken a single course in nutrition/dietetics. Sigh.

My point is, be savvy about where you get your information. Just because someone has credentials in one field does not make them a credible source of information in another field.

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Mon, 06 Jun 2016 20:55:23 +0000fireychihttps://fierychiwoman.wordpress.com/2016/06/06/egos-galore/So it’s been a while. I had a computer die and traded for another one. In between, I did a once a week, massage class at a local massage school. The teacher was cool. I was her assistant. The students were less than impressive. Eye rolling, phone scrolling, easily offended, cry babies. I never felt welcomed. Only when they found out I had over 10 years experience as a LMT, did anyone even bother to pick my brain. When I offered some extra curricular, knowledge. I was often met with heavy sighs and eye rolls. Like they didn’t need anymore knowledge. The egos in the room made it hard to breath. I had a few of those in my class, when I was studying. A little knowledge is a dangerous thing.

Therapists who think they are the greatest thing, without question. These people are the ones who end up harming clients. Going beyond their scope of practice and thinking they know what’s best for their clients. I work with one. They can’t imagine how anyone would not adore them and their bodywork. Even after complaints from fellow therapists and clients. They’re clueless and/or delusional.

I learned and accepted at the beginning of this journey; that I’m not the greatest. This is why we take continuing education classes. I’m always going to improve. I know my work is not for everyone and I have no problem referring a client to another therapist, who might give them better results. I don’t trash talk other therapists in front of clients!

I work with another therapists who’s work is amazing. I have profound changes when I get bodywork from them and have referred clients to them. My problem is that they always have to slip into the conversation how awesome they are. If I say “You and I had a great client load this week.” They’ll respond. “Yeah, but you’ve been here for a long time and I’m new.” That little, cunty dig was unnecessary, and they make sure they always have the last word. It irritates me to no end. I have to keep peace at work, so I let it go. That is my ego exercise.

These past few months have been so filled with ego problems. Everyone wants to be right. Everyone wants to be a winner. I want to be at peace. Not on guard all the time. Worrying about what I’ll say in case someone gets butt hurt. It amazes me that I always seem to be the one who is asked to apologize. Even if I’m the injured party. It’s getting old.

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Thu, 12 May 2016 15:06:39 +0000kellyburtonlmthttps://kellylmt.com/2016/05/12/social-media-ethical-boundaries/I love social media. I use it in my personal and professional life. I can have instant access to family and friends. If somebody in the community has a question that is within my scope of practice, I often get tagged in a post or comment. Therefore others that are not on my “friend list” will often times see my response.

Social media is an easy way to vent about our day. As a massage therapist we must remember to keep in compliance with HIPAA. The HIPAA Privacy regulations require health care providers and organizations, as well as their business associates, develop and follow procedures that ensure the confidentiality and security of protected health information (PHI) when it is transferred, received, handled, or shared.

You have to be very careful not to cross ethical boundaries with social media. Even though you may not list a person’s name but you vent about a clients/patients session, you are violating MAJOR ethical boundaries.

If you as a massage therapist complaining about XYZ on social media, that is sending a REG FLAG to a potential customer/employer. “Are you going to complain about me if I see you?” Its not hard to connect the dots, especially if you list where you work.

1. If you need to vent, (which we all do) don’t splatter it on social media. It looks very unprofessional, unethical and unpleasant in the massage therapy profession.

2. If you are employed by a business you are representing THEM.

3. If you are self employed, you are setting yourself up for disaster with past, present and future clients.

4. The Trust that client had with you just went out the window.

5. Once you hit post, its out there to the world. Negative comments circulate quickly.

Social Media can be a beautiful tool to use but if its misused can become a death sentence to you and the massage therapy profession. If you can to work in healthcare, I guarantee the hospital is going to look at those social media accounts.

I recently have read lots of controversy over Dry Needling, a new term for what I have always thought to be Acupuncture. Recently the Physical Therapy board has approved that MOST states recognized that Dry Needling is within the scope of practice for PTs.

Dry needling is a technique physical therapists use (where allowed by state law) to treat myofascial pain. The technique uses a “dry” needle, one without medication or injection, inserted through the skin into areas of the muscle, known as trigger points.

So my question is could Dry Needling be in a massage therapist’s scope of practice? LMTs focus on trigger points and myofascial pain too. I have mixed feelings about this modality and with scope of practice boundaries.

I would love to hear other massage therapists opinions. When I Google “Dry Needling and Massage Therapy”, it gives links to certification trainings for massage therapists.

I came across this article recently detailing how to raise kids on low-carb diets and I honestly can’t even. It’s one thing for adults to choose to follow low-carb diets. It’s a whole other kettle of fish to inflict them on children.

The post is written by a pharmacist. I’m sorry, when did pharmacists become keepers of nutritional expertise? Has this woman never heard of scope of practice? You don’t see me running around telling people to start popping pills for various ailments. This is because I’m a dietitian, I know about food and nutrition. Medications I leave to doctors, NPs, and pharmacists.

Okay, so why is this pharmacist advocating for a low-carb diet for kiddos? The opening statement reads: “Childhood obesity is a huge problem today. Lots of parents are wondering – how do you raise kids without feeding them excessive carbs?”

Are they? Parents, can you confirm this? It frightens me to think that this may be true.

The article makes a disingenuous comparison between two packed lunches and essentially equates low-carb to “junk food” free and, as far as I can tell, low/no grain. Trotting out that erronous message that modern wheat is different from ancient wheat and therefore the food of the devil.

Does the author bother to mention that grains contain nutrients that are important for growth and development in children? Nope. No mention of ensuring that alternative sources of B vitamins, fibre, vitamin E, certain proteins, and so on must be found for children to be healthy on such a diet. Certainly no mention that this type of diet may be setting up children for a lifetime of disordered eating.

There are other ways to prevent childhood obesity and to promote healthy eating habits in children. Forced orthorexia and elimination of food groups is not one of them. Instead, focus on providing your children with nutritious options. Involve them in food prep. Allow them to have occasional treats. Model healthy eating habits and a positive relationship with food. Eat together as a family as often as possible. Carbs are not the enemy.

]]>https://nutritiontruthblog.wordpress.com/2016/02/19/registered-dietitian-nutritionist-wellness-coach-arent-they-all-the-same/
Fri, 19 Feb 2016 17:50:28 +0000nutritiontruthbloghttps://nutritiontruthblog.wordpress.com/2016/02/19/registered-dietitian-nutritionist-wellness-coach-arent-they-all-the-same/The answer is a resounding NO! “Nutritionist” is a broad term that applies to anyone who works with food and nutrition, including Registered Dietitians (RDs). But not all Nutritionists can be called a Registered Dietitian. RDs are also included in the term “Licensed Nutritionist”.Please be selective about the “nutrition experts” you listen to.

As it stands now, Registered Dietitians (RDs) are the only qualified clinical health professionals that assess, diagnose, and treat diet and nutrition-related problems on an individual and wider community health level. They counsel clients in making practicaland balancedfood choices to support their unique lifestyle and improve health. They are also trained in medical nutrition therapy for chronically ill and hospitalized patients, and patients with specialized needs like vegetarian nutrition, diagnosed food allergies, inflammatory bowel disease, dialysis, liver disease, bariatric surgery, chemotherapy, etc. This requires training in food science & composition, biochemistry, gastric and IV tube feeding, food-drug interactions, and calculating individual caloric and nutrient needs, among other skills. RDs are guaranteed to have a solid foundation in these skills because the RD credential is nationally regulated, so every RD in every state must: (1) graduate from an accredited 4-year Nutrition Science and Dietetics program, (2) successfully complete a supervised practice period (accredited dietetic internship), (3) pass the national RD exam, (4) earn continuing education credits throughout their careers, and (5) operate by an established code of ethics and standards of practice.

“Nutritionists” are a mixed bag depending on where you live. Because not every state requires a “nutritionist” to have a license, the term “nutritionist” has no national standard or accountability. Some nutrition professional other than RDs are qualified to practice nutrition, and are well-studied with a degree in nutrition…they may even have a license to practice nutrition in their state and may work along side RDs. Others may have minimum or no training in nutrition, like one course or even one workshop in nutrition. Wellness Coaches also fall into this general category of Nutritionists – they may have real training, but many do not, and none are qualified to do what an RD does. Another note…just because someone is a medical doctor (like someone who has a T.V. show), doesn’t mean they know the specifics of nutrition, dietetics, & food science…those are not topics that doctors automatically get in-depth training on, unless they take a lot of nutrition-related electives in med school. So, the next time a “nutritionist” tries to put you on a 1-month juicing cleanse, or tells you to never eat grain again, ask to see their credentials and just know to take what they say with a grain of salt.

]]>https://rotherhamgpbulletin.wordpress.com/2016/01/19/comparison-of-intended-scope-of-practice-for-family-medicine-residents-with-reported-scope-of-practice-among-practicing-family-physicians/
Tue, 19 Jan 2016 15:42:21 +0000TRFT Library & Knowledge Servicehttps://rotherhamgpbulletin.wordpress.com/2016/01/19/comparison-of-intended-scope-of-practice-for-family-medicine-residents-with-reported-scope-of-practice-among-practicing-family-physicians/Importance Narrowing of the scope of practice of US family physicians has been well documented. Proposed reasons include changing practice patterns as physicians age, employer restrictions, or generational choices. Determining components of care that remain integral to the practice of family medicine may be informed by assessing gaps between the intended scope of practice of residents and actual scope of practice of family physicians.

Objective To compare intended scope of practice for American Board of Family Medicine (ABFM) initial certifiers at residency completion with self-reported actual scope of practice of recertifying family physicians.

Design and Participants Cross-sectional data were collected from a practice demographic questionnaire completed by all individuals applying to take the ABFM Maintenance of Certification for Family Physicians examination. Initial certifiers reported intentions and recertifiers reported actual provision of specific clinical activities. All physicians who registered for the 2014 ABFM Maintenance of Certification for Family Physicians examination were included: 3038 initial certifiers and 10 846 recertifiers.

Exposures Initially certifying physicians vs recertifying physicians.

Main Outcomes and Measures The Scope of Practice for Primary Care score (scope score), a psychometric scale, was calculated for each physician and ranged from 0 to 30, with higher numbers equating to broader scope of practice. Recertifiers were categorized by decades in practice.

Conclusions and Relevance In this study of family physicians taking ABFM examinations, graduating family medicine residents reported an intention to provide a broader scope of practice than that reported by current practitioners. This pattern suggests that these differences are not generational, but whether they are due to limited practice support, employer constraints, or other causes remains to be determined.

]]>https://studentnurseresource.com/2016/01/05/the-role-of-the-nurse-within-the-u-s-healthcare-system-2/
Tue, 05 Jan 2016 15:15:32 +0000kechiiheduruandersonhttps://studentnurseresource.com/2016/01/05/the-role-of-the-nurse-within-the-u-s-healthcare-system-2/Role of the Nurse in U.S. Healthcare system

The Role of the Nurse within the U.S. Healthcare System

The role of nurses varies from culture to culture in regards to the delivery of patient care and professional responsibilities. These differences in nursing practice include the role of the nurse, scope of practice, and legal environment as well as the requirements for accountability and the relationships between nurses and physicians.

This topic addresses some of the issues discussed under the nurse of the future core competencies, including professional standards of practice, accountability, concept of autonomy and self-regulation in nursing practice, role of the nurse as patient advocate, ethical principles. The nurse practice act and the nursing scope of practice is also discussed. The module has links for further reading and resources.

The following presentation will provide you with a brief description of the roles of the nurse within the United States healthcare setting.

The Standards of Care should be used in conjunction with the Scope of Practice which addresses the role and boundaries of practice for registered nurses. The professional practice of the nurse is characterized by the application of relevant theories, research, and evidence-based guidelines to explain human behavior and related phenomena. Such application also provides a basis for nursing intervention and evaluation of patient-oriented outcomes.

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Fri, 13 Nov 2015 21:41:18 +0000Catherine Knoxhttps://essentialsofcorrectionalnursing.com/2015/11/13/the-challenges-and-distinguishing-features-of-correctional-nursing-part-3/The last two weeks we explored two of the challenges in becoming a correctional nurse and how once mastered, the results are practices that distinguish correctional nursing from other areas of nursing practice. A final cultural challenge for nurses in the land of correctional Oz, a phrase Lorry coined for nurses new to the specialty, is to develop a caring practice, consistent with professional principles. Many correctional nurses lament “how can I be caring when the place where I work exists for the purpose of punishment?” In correctional settings, staff are cautioned against touching an offender, unless it is necessary to perform some task, such as a pat down search. Some places go as far as considering touch, an act for which staff can be disciplined.

Common expressions of caring in nursing such as therapeutic touch or an empathic disclosure of personal information are often prohibited or extremely limited in the correctional setting. These acts earn a nurse derision from other staff, particularly custody staff, and they will be taunted as a “chocolate heart”, “hug-a-thug” or “convict lover.” Correctional officers will not trust nurses who violate the facility’s expectations about maintaining boundaries, to act professionally in other encounters.

Caring however remains a central tenet of correctional nursing and is vital to the therapeutic relationship. Another distinguishing characteristic of the specialty, is that the expression of caring, emphasizes interpersonal communication rather than physical contact and use of self to convey empathy. Correctional nurses express caring when their interactions with patients convey respect, are nonjudgmental, acknowledge the validity of the patient’s subjective experience, are not rushed and are done in the genuine interest of the patient (ANA 2013).

Correctional nurses have described how, it is first, necessary to establish a professional relationship with custody staff before they can negotiate delivery of compassionate nursing care. This means having acting, behaving and speaking in a ways that are consistent with professional practice standards. The most recent version of the Scope and Standards of Practice for Correctional Nursing were published in 2013 and now are identical to those of nursing generally. So a correctional nurse practices as any nurse does; it is only the place and population served that differ.

An example of how a professional relationship with custody staff is established, is in accounting, not just for controlled substances, but for all the sharp instruments as well. This is usually done at the beginning and end of every shift. This means all of the instruments, including those in the dental clinic, those kept in the inpatient and outpatient medical areas, and the lab as well plus every needle on site…it can be an arduous task. This degree of accountability is necessary because sharps can be used as weapons, to do tattooing and to shoot drugs, all dangerous and prohibited activities in a correctional facility. Nurses count sharps because it is necessary for security, not as part of health care delivery. A missing sharp means that the whole facility will be locked down and searched until the item is found. I have experienced an entire facility being locked facility down, for hours on end, because a single insulin syringe could not be accounted for. No other work, even delivery of health care takes place, until the “sharp” is accounted for. Sometimes nurses balk at the requirement for counting or act as though it isn’t as important as patient care. However, failure to account for sharps is not only dangerous, but it undermines the professional relationship with custody staff.

The ANA standards for professional practice are also important because they help to define and protect the role of nurses in the correctional setting. We provide health care in a setting where custody staff, facility commanders and correctional administrators have little or no knowledge of the standards for nursing care, let alone much appreciation for the limits of nursing practice in state law, unlike traditional health care settings. A nurse cannot rely on the correctional facility to have practices and procedures that are compliant with state law or professional practice standards. They may be the only nurse for a small facility and have no other health care professional to provide advice, other than a part time visiting physician. Even in large correctional facilities with many nurses, including nurses in management, practice creep can occur for an individual nurse whose primary interaction during a shift is with correctional officers and inmates who don’t know or appreciate the nurse’s scope of practice. Individual nurses must therefore establish these boundaries on their own, or risk violation of the law and the potential for action on their license.

There are many examples where nurses are asked to perform work that is outside the scope of practice or not consistent with professional standards. A nurse may be asked to approve use of pepper spray or endorse the use of a restraint chair and hood; decisions which are not in the interest of the patient or their health care. For example, another friend of mine, Lynda Bronson, was threatened with insubordination for refusing a direct order from the Warden to forcibly medicate an inmate who was in segregation and screaming obscenities at the officers.

The Warden threatened Lynda three times with insubordination and yet she stood her ground and explained that she did not have a medical order that would allow her to forcibly medicate the inmate. These are tough situations to be in and correctional nurses must be experts in communication, collaboration, and problem solving, with Wardens as well as correctional officers. These skills are necessary to arrive at compromises that solve problems, like screaming obscenities and gravely disordered behavior, while keeping the patient and staff safe.

Well done, this is experienced as practice autonomy, one of the most preferred and distinguishing characteristics of correctional nursing. Nurses who are clear about the standards and boundaries of their practice in correctional settings earn the respect of custody staff and are able to negotiate better outcomes for their patients.

To sum up, correctional nurses provide health care from within the justice system, to a disparate population of prisoners with great disease burden. These features; the location and population served, along with the nurse’s independent negotiation for care, define and characterize correctional nursing.

They say that once a nurse has resolved these cultural challenges, he or she will stay in the Land of Correctional Oz forever. As Tonia Faust, the nurse from the Louisiana State Penitentiary said in The American Nurse “There is a purpose for me here”. Those that don’t survive the transition, leave, usually within the first year.

Do the challenges portrayed over the last three weeks fit the experience you had transitioning into the field of correctional nursing? Are there aspects of your practice in correctional nursing that are different from other nursing fields that have not been highlighted in this series? Please share your thoughts about these questions by responding in the comments section of this post.

If you would like to read more about caring and professional practice in correctional nursing see Chapter 2 on the ethical principles of correctional nursing and chapter that discusses the elements of professional correctional nursing practice in our book, Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

If you would like to order a copy of The Wizard of Oz Guide to Correctional Nursing go to Lorry’s website, Correctionalnurse.net to order through Amazon.

Photo credit:Jaka Vinsek, Cinematographer The American Nurse

]]>https://essentialsofcorrectionalnursing.com/2015/11/06/the-challenges-and-distinguishing-features-of-correctional-nursing-part-2/
Fri, 06 Nov 2015 21:16:57 +0000Catherine Knoxhttps://essentialsofcorrectionalnursing.com/2015/11/06/the-challenges-and-distinguishing-features-of-correctional-nursing-part-2/Last week’s post described the challenge of knowing the impact of the law on the delivery of health care in the correctional setting. Knowledge of the law and prisoners’ rights is one of the distinguishing features of correctional nursing practice. This week’s post describes the second challenge correctional nurses encounter which is the patients themselves. There is no denying that our patients have been charged with or convicted of breaking the law, sometimes violently. For the most part, knowing the nature of their crime is irrelevant to the provision of their health care, but it is also true, that offenders tend to think and behave in ways that get them in trouble with the law. These criminogenic thoughts and behaviors pepper a nurse’s interaction with their patients.

This is otherwise known as “the Con”, which is defined as the purposeful effort to deceive, manipulate or take advantage of another. Convicts gain respect from others when they “con” someone else and the person who gets conned is considered “weak”. Being weak makes one vulnerable to further exploitation.

Correctional nurses describe this as being manipulated. How it often works, is that an offender requests health care attention because of, let’s say, chronic low back pain, for example. In correctional facilities the offender will always be evaluated by a nurse first, who will determine what to do about the request. It may be that with some education, the offender can take care of it themselves, or a nursing intervention may take care for the problem, or finally, the nurse may decide that the offender needs to be seen by another provider and if so will make a referral.

Sometimes the offender will ask for something for which there is no objective evidence they need. The offender’s request for a narcotic analgesic to ease the chronic pain in his back, is likely not to be supported by objective findings. The request could simply be that the offender is seeking drugs; it could also be to sell or used to pay back a loan. The offender probably will also ask for an extra mattress or pillow. This also may be used to repay a debt or it could be just an effort to stand apart from others, as having something “special”.

If there is a medical need, these may be appropriate to give the offender. But if they are not needed and the nurse acquiesces, the offender has successfully “conned” or manipulated the nurse and achieved a secondary gain. The nurse is then considered “weak” and sought out for other such requests. Correctional nurses joking refer to this dynamic when we say “you know you are a correctional nurse when your patients make up reasons to see you and then don’t want to leave until they get what they came for.”

This gives rise to another distinguishing feature of correctional nursing practice which is the emphasis on the assessment of objective signs and symptoms and the accuracy of the resulting clinical judgment. Our patients subjective complaint may be embellished and critical details may be withheld (remember the example last week about the inmates who drank printer fluid). The conditions within which our assessments are done, often are not conducive to the patient giving a full and candid account of what led up to the request for care. Erring on the side of leniency in the absence of objective findings can result in being seen as, easy to con, and as word gets around, the nurse will be bombarded with inappropriate requests thereafter.

Making the wrong decision though, can also result in harm to the patient. An error in clinical judgment can be because the nurse’s skills are poor or undeveloped, or because the nurse lacks of sufficient knowledge. It can also occur, when a nurse has become cynical about their patient’s criminality and views every request as likely to be devious or untrue. This belief will cloud a nurse’s clinical judgement and important clues to the patient’s condition missed.

While they may be manipulative and sometimes untruthful, they have legitimate health care needs as well. So knowledge about the health problems that characterize the population we care for is a critical piece in achieving more accurate clinical judgments.

According to a report issued this year by the Bureau of Justice Statistics, forty percent of the incarcerated or detained adult population are diagnosed with a chronic medical condition compared to a third in the general community. Diabetes is twice as prevalent among the correctional population compared to a matched sample in the general community and hypertension is 1 ½ times more common. In terms of communicable disease, TB infection and STDs among offenders in correctional settings are twice the rates in the general community and hepatitis is six times the community rate (Bureau of Justice Statistics 2015 Medical Problems of State and Federal Prisoners and Jail Inmates 2011-12).

The racial and ethnic disparities of the criminal justice population are substantial. More than 60 percent are considered racial or ethnic minorities in the general community. One in every three black men and one in every six Latino men will serve time in prison or jail during their lifetime, compared to one in 17 white men. The same racial and ethnic disparities exist among women; one in every 18 black women and one of every 45 Latina women will be incarcerated in their lifetime compared to one of every 111 white women (The Sentencing Project at http://www.sentencingproject.org/template/page.cfm?id=107).

There are age and gender disparities among the incarcerated population as well. The overwhelming majority are men and they are relatively young in age. While women are in a minority, representing only 9% of all incarcerated persons, their population is increasing at much faster rates than men. Incarcerated women have high rates of traumatic history, particularly child abuse and domestic violence; their convictions are usually drug or drug related and most also are responsible for raising children (Bloom, Owen & Covington 2005).

Older prisoners also are a small percentage of the total (8%) incarcerated population but their numbers are growing at much faster rates because of mandatory sentencing and increasing numbers of extremely long sentences received. In fact the population of prisoners over the age of 65 increased 63% compared to a 0.7% growth for all other ages between 2007 -2010 (Human Rights Watch (2012) Old Behind Bars at https://www.hrw.org/report/2012/01/27/old-behind-bars/aging-prison-population-united-states).

Juveniles are another small but important group, with unique health care needs. They represent less than 1% of all persons incarcerated. Although incarceration rates for youth are declining, we know that incarceration decreases the likelihood of high school graduation and increases the likelihood of subsequent incarceration as an adult (The Hamilton Project 2014 at www.hamiltonproject.org).

What these statistics mean is that correctional nurses provide population-based health care. Nurses must be knowledgeable and vigilant in their clinical judgement, in order to identify and appropriately treat the health conditions that occur more frequently within each of these population subgroups (blacks, Latinos, women, children and the elderly). This focus on the uniqueness of each individual conflicts with one of the major norms of the correctional system; that incarceration is done to deprive a person of their individuality. No one gets special treatment, no one can be singled out and the rules are applied to all, firmly, fairly and consistently.

This norm about uniformity among prisoners, conflicts with the expectation and science of patient-centered care. Yet when individualization is in the best medical interests of the patient, correctional nurses are obligated to speak up. Patient advocacy, therefore is another distinguishing feature of correctional nursing. Often the nurse will have to act alone because they are the only health care provider at the scene.

An example of nursing advocacy for the individual needs of patients is shackling. Shackling is a security measure to prevent escape when prisoners are taken outside the confines of a correctional institution. In some correctional facilities or systems this is a routine practice applied to all, even pregnant women during labor and delivery. The American Medical Association, the American Public Health Association and the American College of Obstetricians and Gynecologists have each decried this as an unsafe and potentially harmful practice. Some states have even passed legislation prohibiting the use of shackles during labor and delivery. And yet we know the practice continues, so it often is the individual nurse who must insist the shackles be removed for the sake of the patient and their care.

In addition to knowledge, vigilance and advocacy for the needs of the population served, correctional nurses must be generalists in their competency to provide all types of nursing care. Like the prisoners themselves, who are not being able to choose their provider, correctional nurses do not get to choose their patients. A friend of mine and author of one of the chapters in our Essentials text, Roseann Harmon, tells a story about one of her first experiences in correctional nursing. She had been hired at the county jail because she had mental health experience. One evening the nurse manager came to her and said “Roseann, we have a woman out in the squad car at intake and she is in active labor. I am going to need your help because we are the only ones close by. Will you go get the OB pack?” Roseann gulped and said, “But I’m the mental health nurse, not an OB nurse.” The manager responded, “Well you are a nurse and so am I. We are the only ones here right now so we have to respond and we will do it together. This woman needs us.” Well, Roseann survived this experience and still tells the story years later, reminding us not to let our general nursing expertise diminish.

The second part of the ANA’s definition of correctional nursing is that the population cared for are prisoners. To summarize our population is characterized by criminality; ethnic, racial and gender disparities and has a high burden of disease. This population has had little in the way of regular health care prior to incarceration and are illiterate about self-care and health generally. Correctional nursing is defined as being responsive to the health care needs of people during their incarceration.

What are the best ways to maintain your knowledge and competencies as a generalist in nursing practices when there are some many changes in the science and best practices of health care? Please share your thoughts and resources that you think help nurses stay current in our field by responding in the comments section of this post.

If you would like to read more about the health care challenges and characteristics of the incarcerated population, see many chapters in our book, Essentials of Correctional Nursing, devoted to the nursing care of women, juveniles, the elderly, the racial and cultural groups as well as those with chronic disease and mental illness. Order a copy directly from the publisher or from Amazon today!

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Fri, 30 Oct 2015 19:50:45 +0000Catherine Knoxhttps://essentialsofcorrectionalnursing.com/2015/10/30/the-challenges-and-distinguishing-features-of-correctional-nursing-part-1/What career did you want for yourself when you graduated from nursing school? Did know you wanted to be a correctional nurse? You probably never heard of it, right? This is me back in 1973 and I had never heard of correctional nursing either. Most correctional nurses will tell you that they never planned to be in this field. The reasons they give for trying it out included:

Wanting to try something different.

It was close to home and convenient.

They knew someone else who was a correctional nurse and suggested it.

I made the change because I was bored with hospital-based psychiatric care. The opportunity to develop a health care program for offenders in state prisons came at the perfect time and I took on the challenge and have had a chance to make a difference in the lives of those who could not do so for themselves. I thought I would stay about five years and move on, but it has been 31 years now. The next several posts will explore the challenges of becoming a correctional nursing specialist, the features that distinguish the specialty and explore why nurses stay in the field.

Nurses have advocated for the health and well-being of prisoners practically since the beginning of time. These include Florence Nightingale, who did some of her best work in England’s poor houses in the mid-nineteenth century as well prisoners during the Crimean war, Clara Barton, who cared for prisoners of war in the Civil War, and Dorothea Dix who was responsible for prison reform in the 1800s. The American Nurses Association has considered correctional nursing a specialty since 1985 and publishes standards for the scope of professional practice in correctional nursing.

The Institute of Medicine report The Future of Nursing: Leading Change, Advancing Health (2010) acknowledges correctional nursing when commenting on diversity in the nursing profession, stating that nurses will be present anywhere there are people who have healthcare needs. Those of you who watched the movie, The American Nurse, met Tonia Faust, a correctional nurse, and hospice coordinator at the Louisiana State Penitentiary. Four of the 75 nurses portrayed in the book, The American Nurse, were providing health care in correctional facilities at the time they were interviewed. We don’t really know how many correctional nurses there are because many state boards of nursing don’t include this as an option when indicating your place of employment or area of practice.

My co-contributor, Lorry Schoenly, likens the transition to correctional nursing to the popular tale, The Wizard of Oz when Dorothy Gale, walks out into the Land of Oz, after her prairie home landed on the Wicked Witch of the East, following a tornado ride from Kansas. Our first experiences with correctional officers, handcuffs, sally ports, metal detectors, crossing the yard and pop counts brings to mind Dorothy’s admonition to her little dog “This isn’t Kansas anymore, Toto!” In fact Lorry, published a book by the title, The Wizard of Oz Guide to Correctional Nursing, to help nurses manage the transition to this very different setting.

Well the first cultural challenge for nurses after they have arrived in the Land of Correctional Oz is the realization and understanding that our services are secondary to enforcing the law and protecting the public. This is the primary purpose of incarceration in the United States. The people whose health we are responsible for, are being detained against their free will, as punishment. Even so, the Supreme Court has granted prisoners a constitutional right to health care under the 8th amendment. Failure to do so is considered “cruel and unusual punishment.” The court’s reasoning was that “it is but just, that the public be required to care for the prisoner, who cannot, by reason of the deprivation of his liberty, care for himself.”

This is not just a cultural challenge but one of the distinctive features of correctional nursing practice. The first part of the ANA definition of correctional nursing, is that it takes place at the intersection of an individual and their involvement with the justice system. Legal precedents have been the primary means by which the delivery of health care in the correctional system has been shaped.

The courts have established that inmates have the right to health care during incarceration which includes:

Unimpeded access to care

Care that is ordered must be provided

Entitled to professional clinical judgment

These three rights are referred to as the three legged stool of the Eighth Amendment rights to prisoner health care and they are operative in almost every aspect of a correctional nurse’s daily practice.

Here is an example of the application of these rights to health care from my early experience in correctional nursing. In this instance, three inmates, working in the print shop, drank printing fluid, in an attempt to get high. All three became sick but they did not seek medical attention because the nursing staff would have to report them to security for stealing the printer fluid. One inmate died as a result of the delay in treatment. The courts found a violation of the eighth amendment because the inmates’ access to health care attention was impeded, due to the threat of being reported and subsequently disciplined. In this case, a correctional facility’s requirement for reporting prohibited conduct impeded access to care and resulted in a finding of “cruel and unusual punishment”. The legal right to health care, its practical interpretation and application in the correctional setting is one of the distinguishing features of correctional nursing.

Do you have some good examples of how legal considerations impact the practice of correctional nursing? If so please share by responding in the comments section of this post.

If you would like to read more about legal considerations in correctional nursing please see Chapter 3 written by Jacqueline Moore in the Essentials of Correctional Nursing; the first and only textbook written so far about the practice of nursing in this specialized field. Order a copy directly from the publisher or from Amazon today!

If you would like to order a copy of The Wizard of Oz Guide to Correctional Nursing go to Lorry’s website, Correctionalnurse.net to order through Amazon.

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Mon, 28 Sep 2015 14:50:44 +0000Donald Balasahttps://aamalegaleye.wordpress.com/2015/09/28/further-information-on-sb-110/https://healthierdaysareahead.wordpress.com/2015/09/04/minor-surgery/
Fri, 04 Sep 2015 23:26:55 +0000healthierdaysareaheadhttps://healthierdaysareahead.wordpress.com/2015/09/04/minor-surgery/Depending upon the state, NDs may be licensed to perform minor office procedures and surgery. The CNPA has been working on modernizing ND scope of practice that reflects our training and education and brings us on par with many other states. Part of the modernization of the law includes being able to perform minor office procedures.

Today in my minor office procedures class I got to practice doing an interrupted suture on a banana. This simple interrupted stitch is a suturing technique used to close wounds. It took sometime to do each stitch but I was able to catch on rather quickly. I of course need more practice to improve my technique but considering it was the first day, I think I did well. Check out my suturing skills!

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Fri, 04 Sep 2015 16:58:23 +0000Catherine Knoxhttps://essentialsofcorrectionalnursing.com/2015/09/04/knowledge-resources-for-medication-management/The American Nurses Association statement on the scope of practice for correctional nurses requires that nurses be knowledgeable of the medications administered, including dosages, side effects, contraindications and allergies. Nurses also must be able to teach and coach patients so that they know what medications they are taking, the correct dose and frequency (2013). Many more drugs have been developed to effectively treat a wider variety of conditions in the last several decades and new drug formulations established which reduce treatment time, improve adherence and reduce the burden of side effects. With the proliferation of treatment choices available to prescribers today, the scope of knowledge required of nurses has expanded as well.

The types of health problems presented by our patients during incarceration is very broad therefore correctional nurses must maintain more expansive knowledge about the drugs likely to be prescribed than nurses who specialize their practice to a certain acuity (e.g., critical care) or particular health problem (e.g., kidney dialysis). It is impossible to memorize all this information so what references should a nurse use to aid their knowledge about medications these days? What are the drug references that you use?

A couple years ago another nurse and I were talking about a patient and one of the drugs that had been prescribed. I went in search of the big red text from the American Hospital Formulary Service. He turned to the computer and typed the drug’s name into Wikipedia and before I left the room he had the information we were looking for. The problem is that anyone can contribute information to Wikipedia and so the accuracy and completeness of drug information on this site has been examined. Drug information on Wikipedia relies most heavily on news articles and commercial websites rather than evidence-based material and the information, especially that which is safety related is not reliably updated (Koppen, Phillips & Papageorgiou 2015).

Nurses in one survey in the U.S. favored using the Physician’s Drug Reference (PDR) or a text written especially for nurses like Lippincott’s Nursing Drug Handbook (Gettig 2007). In another survey nurses reported that, other than the PDR, they relied most on other colleagues in the workplace. The problem with relying on co-workers for information about drugs is that the individual may not be available or authoritative on the subject. Access to information and ease of use were the most important factors in nurses’ choice of drug information resources so that quick and concise answers could be obtained (Ndosi & Newell 2010). As drug information has become more available in electronic format it can be more quickly accessed and is becoming a more reliable reference for busy correctional nurses.

The following is a list of drug references and applications that are available on line and can be obtained for free:

National Library of Medicine has three databases that are useful for nurses in medication management. The first is the Drug Information Portal which provides information on 53,000 drugs from government agencies and scientific journals. The second is Drugs, Herbs and Supplements providing information for patients about the purpose of drugs, correct dosages, side effects and potential interactions with dietary supplements and herbal remedies. Last is a database designed for use in emergencies and developed to help identify unlabeled pills called Pillbox.

Epocrates is one of the most widely used and highly recommended drug references. In addition to drug information the basic package which is free has a dose calculator, drug-drug interaction checker which includes OTC medication and a pill identification program. For an annual fee the program can be upgraded to access medical information, diagnostic information, a medical dictionary and infectious disease guidelines.

Medscape Mobile is a combination medical reference and drug database. In addition to clinical reference for 8,000 drugs, herbals and supplements it includes a robust drug-drug interaction checker and a dosage calculator.

A final resource that should be available at every correctional facility is the telephone number for the poison control center. This is a national hotline number (1 800 222-1212) which connects to the nearest poison control center. Most poison exposures can be treated locally if contact is made with a poison control center because they are staffed 24 hours seven days a week by health care professionals with special training. The facility should also stock a supply of antidotes for various types of poison. A consensus guideline published in the Annals of Emergency Medicine (2009) recommended stocking 12 antidotes available for immediate use in treatment (2009). Since then several poison control centers have lists on-line of recommended antidotes to have on hand.

Availability of antidotes is a decision that should be made by the facility medical director in consultation with the supplying pharmacy. Usually they are stored with other emergency medications. Nurses should be familiar with each antidote stocked at the facility for use in medical emergency care. Here is a link to a list of common drugs and antidotes that nurses should know about.

Are there any knowledge resources for nurses in managing medications that are not described here and should be? Please let us know about them by responding in the comments section of this post. For more about the opportunities and challenges in correctional nursing order a copy of our book, Essentials of Correctional Nursing directly from the publisher or from Amazon today!

Lauren Quinn, PT Student – Clinical placement at the College of Physiotherapists of Ontario

When I learned that I would be completing my clinical placement at the College of Physiotherapists of Ontario, I was apprehensive. In the world of PT students, I have found that the College is often misunderstood and sometimes negatively perceived.

From creating standards to performing practice assessments, aka “audits,” to discipline hearings, my impression was that the College would be disciplinarian-like…but I could not have been more wrong. Within hours of working there, I quickly learned how supportive the College is to its members and how valuable a resource the staff are to all.

Some people may see the College as an enemy to PTs because of its duty to protect the public. What might not be clear to all is that the College protects the public by actually working withphysiotherapists to make sure they are ethical, competent and safe practitioners.

Being self-regulated is a privilege.

Why would I spend my time and my resources to become a trained physiotherapist if anyone could call themselves a PT and open their own practice?

As a future PT, I am comforted knowing that the College is there to maintain the reputation of the physiotherapy profession and ensure the competency of practicing members.

Practice Assessments

When a PT thinks of the College, they most likely think about—and dread—the possibility of being selected for a practice assessment. That dread comes from a lack of understanding.

I believe many PTs aren’t aware of the true nature of these assessments. Assessments are not designed to trick and punish PTs, but instead the College’s goal is to have members improve their practices based on their own reflections and a structured discussion with a peer.

The assessment questions are available on the website and PTs can choose their own charts for discussion. Using this approach, the College hopes that PTs will be able to identify and correct any behaviour that may not meet the standards of practice before the assessment.

I was pleasantly surprised to learn that after the assessment is complete, members are allowed to make a submission to the College to share how they have improved their practice if there were areas for improvement. If the member was unable to show that the assessment gaps have been addressed, the College then works closely with that PT to help them to meet the standards by giving them resources or setting them up to work with a peer coach.

Concerns, Complaints and Investigations

Similarly, investigations into concerns about health professional’s behaviour follow a fair and objective process. The College always assumes its members are professional, ethical and competent until there is evidence to prove otherwise. Complaints are thoroughly investigated and the members are encouraged to make a written response to share their side of the story.

Typically, very few complaints are referred to the Discipline Committee, with most issues requiring no action or some form of remediation.

It’s all about the College’s desire to protect the public by coaching physiotherapists to improve and making use of remediation. The College reserves strict disciplinary action for the most serious cases, where the protection of the public is a grave concern.

I wrote this blog post—independent from the College—because of the discrepancy I noticed between the professional perception and the College’s objectives.

College staff believe in the profession the members and is committed to helping members be their best professional selves.

They are available to help PTs in any area of their practice, registration and professional obligations. You can also contact the Practice Advisor.

As I transition into independent practice, making use of the College’s resources and knowledge will help me to be a better physiotherapist and deliver the best care to my patients.

Because isn’t that why we all went through years of school and continuing education—to ultimately help rehabilitate our patients and improve their quality of life—so shouldn’t we support their protection as well?